Physiotherapy For Postoperative Section Of The Flexor Tendons Of The Hand (Method Duran)

Physiotherapy

Traumatic injuries of the flexor tendons of the hand are very common and can leave serious consequences ranging from a simple reduction of force, until a major limitation of flexion, limiting the overall role of the hand.

In this article we will focus on the case of a patient who attended the Emergency Unit of the European Hospital Georges Pompidou (Paris). In this hospital there is a service that specializes in hand surgery, the rehabilitation is conducted according to specific protocols.

The patient of 44 years goes by a domestic accident (breakage of a plate). Presents a deep cut on the palm side of the Zone II of the left index finger. In his case presents no complete vascular injury but a common functional impotence of the Deep Flexor (FCP) and Common Flexor Surface (FCS) and a radial edge of the anesthesia of the finger.

Realizándosele surgery is a suture in the tendon, an anastomosis of the radial collateral artery and a suture of the radial collateral nerve.

The post is smooth and the patient started physical therapy the day after your operation.

Basic Concepts

Then, for a proper understanding, we proceed to explain some basic concepts

2.1) topographical areas

In 1961, the Truth and Michot propose a classification that includes seven anatomical areas to divide the hand. The International Federation of Hand Surgery amends in 1980. Currently comprises 5 zones and 3 fingers for the thumb.

In this case only develop different parts of the fingers except the thumb, as the case of our patient.

Zone 1: Insertion of the distal flexor surface and covers the insertion of the deep flexor of the base of the third phalanx.

Zone 2: Called “No Man’s Land”: It goes from the distal palmar crease to the middle of the second phalanx.

This area is interesting from the anatomical point of view because at this level the deep flexor appears “punch” to the superficial flexor.

Zone 3: Occupies since leaving the carpal tunnel until the digital channel. This area is conducive to good recovery.

Zone 4: Carpal Canal Zone. Corresponds to the carpal tunnel area covered by the annular ligament anterior carpal pulley makes avoiding the phenomenon of string arc during flexion of the wrist. The median nerve is the most vulnerable surface of the channel.

Zone 5: Since the union of the musculo-tendinous flexor to enter the carpal tunnel. In this area, the tendons are surrounded by a paratendón which allows movement of large amplitude. It is a very favorable area for recovery if there is a nerve-associated vascular injury.

2.2) tendon healing

After a long evolution of ideas, all authors agree to define two types of tendon healing:

Extrinsic-healing: where there is a fibroblastic invasion of adjacent tissues, resulting adhesions.

Intrinsic healing-that is the ability of the tendon to regenerate itself through its own intra-tendon fibroblasts to migrate into the lesion.

During tendon repair, Shickland, discovers that the three phases will coexist two of wound healing mechanisms so indivisible.

* An inflammatory phase (3-5 days) characterized by a swelling and a hematoma.

* A fibroblastic phase (3-6 weeks) characterized by a high production of collagen.

* A phase remodelage (6-8 months) in which the maturation and organization of the fibers is a longitudinal mode under the effect of movements and the forces of traction.

Briefly explain the protocols of rehabilitation according to the stage of healing in the tendon that is:

From the day 1-21 after the intervention:

Analytical and global manipulation

Protection tendon (splint)

Tenodesis effect

From day 21 to 45:

Work of the scar (U.S., massage ..)

Passive movements

Active work and active-assisted soft -

Cryotherapy

Beginning 45 days:

Further work on the scar

Working towards an active extension / flexion

Extensor strengthening

Articulate and work towards easing the flexo-extension

3) Rehabilitation

The protocol type of rehabilitation will depend on the cooperation of the patient, the extent of the lesion, the surgical gesture and the use of rehabilitation equipment. Is essential and depends entirely on the patient

The goals of rehabilitation are:

-Promotes healing

-Reduce the incidence of adhesions

-Maintain joint mobility

All the techniques are accompanied by a protective splint in order not to risk the tendon regeneration. Turbiana sorts of techniques:

Technology-active: Active Flexion + Extension active

Semi-active techniques: Passive Flexion + Extension active (Kleinert)

Techniques-passive: Passive Flexion + Extension passive (Duran)

We shall develop the protocol for rehabilitation in post-operative acute phase (day 1-21 after intervention) according to the method Duran protocol used in HEGP

Method Duran (1975):

Passive rehabilitation protocols are based on the method Duran, in 1975, notes that a tendon travel of 3 to 5 mm is sufficient to prevent adhesion formation.

The advantages of passive mobilization are:

which is simple

-There is a low incidence of post-operative rupture

anti-IFP-flexo IFD

Development of the session:

Before starting the mobilization, submerge the hand of the patient in a container with saline solution which aims to soften the scars.

Duran describes 2 types of mobilization to optimize landslides:

One-manipulation (a) in flexo-extension of the IFD, which allows a sliding analytical with respect to FCP FCS.

One-manipulation (b) in flexo-extension of the IFP, which allows a sliding of the two tendons with respect to the structures surrounding the digital channel.

During the exercises, your elbow is in flexion and pronation for a relaxation of the flexors.

Other exercises in this acute phase are:

passive-movements of the metacarpophalangeal

passive-movements of the wrist to create the effect of tenodesis

passive-global movements of the fingers to flex.

The patient wears a splint Duran in thermoformed in the immediate postoperative period and as being very comfortable and very hygienic. This splint prevents stretching and allows the tendon healing. Is a

dorsal protective splint is worn for 4-5 weeks. The position of the hand is:

The wrist palmar flexion 40 °

MF-bent to 60-70 º

IFD-IFP-extension

During the period of immobilization the manipulation must be performed throughout the day by the patient (self-education). For proper self-education, he explained to the patient the need to make 10 moves in under the protection of passive flexion splint to be made at hourly intervals.

Conclusions:

The surgery of the flexor is a complex surgery, particularly injuries in zone 2. The cooperation of the patient (auto rehabilitation) and a correct approach in the acute phase postoperative physiotherapy is essential to obtain an optimal functional outcome.